Patient Information & Health History

Please fill-out this Patient & Health History and HIPAA Authorization Form prior to your appointment. (Looking for the printable form? You can download it here icon_pdf-2x.)

Patient Information & History

at Eye Carumba Optometry before


Vision History

Ocular Health

Please indicate any of the following that apply to you or members of your family:

General Health

Personal Health

Women


Please indicate all medications you are currently taking:


Computer Vision Questionnaire

If you work with computers, please complete this section. If you do not, you may skip to the next section.

Time Spent (hours per day) on a Computer / Device:

Desktop or laptop computer Use (check applicable)

Lighting in work area (please describe)

Are you experiencing any of the following symptoms while at your computer monitor? Check where appropriate:


(If yes, please bring them with you to your eye exam.)

(If yes, please bring them with you to your eye exam.)


Social History


CANCELLATION POLICY

Appointment cancellations made less than 24 business hours prior to your scheduled appointment will result in a $50 cancellation charge. This is an out-of-pocket fee that will not be paid by your insurance company.

PAYMENT POLICY

Payment for services is requested at the time services are rendered. For materials ordered, a 50% deposit is required at the time of ordering, with the balance due on delivery. If our policies pose a financial burden, please ask to speak privately with the Office Manager.

It is the responsibility of the patient to know and understand their vision insurance benefits. The patient agrees to be responsible for all fees not covered by their vision or medical insurance plan.

RETURN POLICY

Professional Services:

Fees for professional services are non-refundable.

Glasses / Ophthalmic Products:

Glasses are complex, custom-made medical devices comprised of a set of frames and spectacle lenses. In the event that a patient is not satisfied with the visual acuity obtained with the prescription lenses provided by Eye Carumba Optometry, the patient will be asked to return to the office for an adjustment of the glasses and, as necessary, schedule a short prescription check appointment with the doctor. Eye Carumba Optometry makes every effort to provide glasses that are accurate to the prescribing doctor's instructions.

This process must be initiated within 90 days of the original purchase date. Returns and refunds are considered by the office management on a case-by-case basis. Restocking fees may apply.

Contact Lens Purchases:

In the case of a prescription change for contact lenses, you may return or exchange unused contact lenses purchased within one year of the original purchase date. Merchandise must be in the original, unopened packaging. All merchandise must be in like-new condition and accompanied by the original receipt.


Eye Carumba Optometry's Use and Disclosure of Your Health Information

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes submission of your health information to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you consent to receive optometric care from Eye Carumba Optometry on the terms described above. You can revoke this consent in writing at any time, but if we have already treated you, sought payment for our services, or performed health care operations in reliance upon this consent, your revocation will not be effective as to those activities. We can decline to serve you if you elect not to sign this consent form.

You have the right to ask us to restrict certain uses or disclosures of your health information. Our Notice of Privacy Practices describes when and how to ask for a restriction.

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:

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